Dynamic Works Program Support Referral
Submission of this referral does not guarantee acceptance into services. Additional information and/or documentation may be requested to determine eligibility and appropriateness for services. **Please note this referral does NOT include transportation services.
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Referral Source
Referral Date
-
Month
-
Day
Year
Date
Referring Agency
Please Select
DSS
CSA/FAPT
Court
School
Parent
Community Partner
Self
Worker Name
Agency
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Relationship to Child
Name
First Name
Last Name
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Legal Guardian/Caregiver Information
Guardian Name
First Name
Last Name
Guardian Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Guardian Email
example@example.com
Caregiver Name
First Name
Last Name
Caregiver Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Caregiver Email
example@example.com
Relationship to Client
Address (If different from client)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Legal Custody Status
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Child Information
Child Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Child Age
Sex
Male
Female
Ethnicity
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Pacific Islander
White or Caucasian
Other
Primary Language
Current School Name
Current Grade
Does the child have an IEP, 504 etc.?
Yes
No
Current Address (or Placement Address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medicaid Number (if applicable)
Insurance Carrier
Policy Number
Is this Client CSA/FAPT approved? ****Please note that FAPT approval is mandatory for enrollment.
*
Yes
No
Please indicate number of hours approved for.
*
Does the child have any diagnosed medical or physical health conditions?
Yes
No
List any current medical diagnoses (if applicable):
Does the child have any physical disabilities, mobility limitations, or special medical needs?
Yes
No
List needs (If applicable):
Is the child currently taking medication?
Yes
No
If so, Please list all current medications
Does the child have any allergies, dietary restrictions or special nutritional needs?
Yes
No
Please list all allergies, dietary needs and reactions:
Has the client ever been diagnosed with a mental health, behavioral health, developmental, or emotional condition?
Yes
No
If yes, please check all that apply:
ADHD
Anxiety
Depression
PTSD/Trauma
Autism Spectrum Disorder
Oppositional Defiant Disorder (ODD)
Conduct Disorder
Bipolar Disorder
Intellectual Disability
Developmental Disability
Other
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Services Requested
Services Requested: Please Check all that apply:
*
Independent Living Coaching
Therapeutic Mentoring
Parent Support
Supervised Visitation
Therapeutic Foster Care
Youth Excellence Center(Teen Center)
Summer Program
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Summer Program
Thank you for your interest in our summer program! Here are some helpful FAQs: Lunch will be provided daily Students will attend a field trip each week. Dates: The program runs every Monday - Thursday from June 22 - July 30 Program hours: 10am - 3pmPopulation: This summer we are serving students ages 12-17
Youth Excellence Center (Teen Center)
Thank you for your interest in our after school program! Here are some helpful FAQs: Dates: The program starts in August and continues Monday - Friday throughout the school year. Our dates align with the school calendar. Dates where school is not in session, including holidays, our after school program will be closed as well. Program hours: 2:30pm - 5:30pmTransportation: Dynamic Works will provide transportation from school to our program each day. If you would like your student to also receive transportation home, please be sure to indicate this on the form below.
Will your student be receiving transportation home, provided by Dynamic Works?
*
Yes
No
Pick Up (This is where student will be picked up before programming)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Drop off address (This is where student will be picked up after programming)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Authorized to Pick Up Child
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Person(s) NOT Authorized To Pick Up Child (if applicable): Appropriate paperwork such as custody papers shall be submitted to the center if a parent is not allowed to pick up the student. NOTE: Section 22.1-4.3 of the Code of Virginia states that unless a court order has been issued to the contrary, the noncustodial parent of a student enrolled in a public school or day care center must be included, upon the request of such noncustodial parent, as an emergency contact for events occurring during school or day care activities. 032-05-252/11 (06/05)
First Name
Last Name
Photo & Media Release
Yes, I give permission for my student's images to be used in videos or photos that may be used in program materials. social media, etc.
No, my student's image may not be used in Dynamic Works images or videos
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Supervision
Referral Type
Initial
Modification
Continuation
Parent/Guardian
*
First Name
Last Name
Child(ren) If multiple children are being referred list all children participating in visitation including DOB and age:
Court Name & Case Number
Is this visitation court ordered?
Yes
No
Are there any protective orders, no-contact orders, or safety restrictions?
Yes
No
If yes, explain:
Are there specific court requirements regarding visitation?
Frequency
Duration
Location Restrictions
Approved Participants
Other
Reason for Supervised Visitation:
Reunification
Maintaining Family Connections
Assessment
Court Requirement
Other
Requested Start Date:
-
Month
-
Day
Year
Date
Requested Visitation Frequency:
Weekly
Bi-Weekly
Monthly
Other
Requested Duration
Requested Location
Community
Office-Based (DWPS)
Virtual
Other
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Therapeutic Foster Care
Briefly describe why the child is being referred for Therapeutic Foster Care.
*
Is the child legally available for placement?
Yes
No
Type of Placement Authority
Court Order
Entrustment
Emergency Removal
Other
What type of placement is being requested?
Therapeutic Foster Care Placement
Foster Care Placement
Emergency Placement
Respite
Planned Placement
Other
Does the child have any immediate safety concerns that would impact placement?
Yes
No
If yes, Please explain:
Placement Considerations: Please identify any known placement needs.
No Young Children
Female Foster Parent Preferred
Male Foster Parent Preferred
Experienced Foster Parent Needed
Must Remain in Current School
Sibling Placement Requested
Other
Is there anything else the placement team should know before determining program appropriateness?
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Needs/Concerns
Current Concerns/Needs Please check all that apply:
Independent living skills
Emotional regulation
Communication skills
Anger management
School concerns
Employment/job readiness
Parenting skills
Boundaries and structure in the home
Decision Making
Frequent Placement Interruption
Other
Are there any known safety concerns, behaviors, risks, or triggers DWPS should be aware of? Please check all that apply:
Substance Use and Abuse
Unsafe Sexual Behaviors
Physical Aggression
Verbal Aggression
Elopement/AWOL
Inappropriate Internet Usage
Property Destruction
Self-Harm and Suicide Risk
Social and Emotional Risk Behaviors
Other
If other, please explain:
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Additional Information
List any current services, therapists, case managers, schools, or supports involved:
Best days/times for services
Please include anything else that would help DWPS understand the client/family’s needs:
Supporting Documents: If applicable, attach any IFSP, IEP, 504 plan, or psychological evaluations. Please note, all documents are kept confidential per Dynamic Works policies.
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By signing your full name below, I certify that the information provided in this referral is true and accurate to the best of my knowledge. I understand that more information may be requested to determine if services are appropriate.
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